Provider Demographics
NPI:1558733196
Name:PARK AVENUE DENTAL GROUP
Entity Type:Organization
Organization Name:PARK AVENUE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRSHORN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-864-4730
Mailing Address - Street 1:3508 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-6006
Mailing Address - Country:US
Mailing Address - Phone:201-864-4730
Mailing Address - Fax:201-864-4734
Practice Address - Street 1:3508 PARK AVE
Practice Address - Street 2:
Practice Address - City:WEEHAWKEN
Practice Address - State:NJ
Practice Address - Zip Code:07086-6006
Practice Address - Country:US
Practice Address - Phone:201-864-4730
Practice Address - Fax:201-864-4734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI015278001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty